Background: Dilated cardiomyopathy (DCM) is the most common cardiomyopathy in children. Patients with severe cardiac dysfunction are thought to be at risk of sudden cardiac arrest (SCA). After diagnosis, a period of medical optimization is recommended before permanent implantable cardioverter-defibrillator (ICD) implantation. Wearable cardioverter-defibrillators (WCDs) provide an option for arrhythmia protection as an outpatient during this optimization.
Objective: The purpose of this study was to determine the strategy that optimizes cost and survival during medical optimization of a patient with DCM before ICD placement.
Methods: A Markov state transition model was constructed for the 3 clinical approaches to compare costs, clinical outcomes, and quality of life: (1) "Inpatient," (2) "Home-WCD," and (3) "Home-No WCD." Transitional probabilities, costs, and utility metrics were extracted from the existing literature. Cost-effectiveness was assessed comparing each paradigm's incremental cost-effectiveness ratio against a societal willingness-to-pay threshold of $50,000 per quality-adjusted life year.
Results: The cost-utility analysis illustrated that Home-WCD met the willingness-to-pay threshold with an incremental cost-effectiveness ratio of $20,103 per quality-adjusted life year and 4 mortalities prevented per 100 patients as compared with Home-No WCD. One-way sensitivity analyses demonstrated that Home-No WCD became the most cost-effective solution when the probability of SCA fell below 0.2% per week, the probability of SCA survival with a WCD fell below 9.8%, or the probability of SCA survival with Home-No WCD quadrupled from base-case assumptions.
Conclusion: Based on the existing literature probabilities of SCA in pediatric patients with DCM undergoing medical optimization before ICD implantation, sending a patient home with a WCD may be a cost-effective strategy.
Keywords: Arrhythmia; Cost-utility; Dilated cardiomyopathy; Pediatrics; Wearable cardioverter-defibrillators.
Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.
Wearable cardioverter-defibrillator for prevention of sudden cardiac death after infected implantable cardioverter-defibrillator removal: A cost-effectiveness evaluation.Heart Rhythm. 2015 Jul;12(7):1565-73. doi: 10.1016/j.hrthm.2015.03.061. Epub 2015 Mar 31. Heart Rhythm. 2015. PMID: 25839113
Potential cost-effectiveness of wearable cardioverter-defibrillator for patients with implantable cardioverter-defibrillator explant in a high-income city of China.J Cardiovasc Electrophysiol. 2019 Nov;30(11):2387-2396. doi: 10.1111/jce.14153. Epub 2019 Sep 25. J Cardiovasc Electrophysiol. 2019. PMID: 31502350
Long-term use of the wearable cardioverter defibrillator in patients with explanted ICD.Int J Cardiol. 2018 Dec 1;272:179-184. doi: 10.1016/j.ijcard.2018.08.017. Epub 2018 Aug 10. Int J Cardiol. 2018. PMID: 30121177
Use of the Wearable Cardioverter Defibrillator in High-Risk Populations.Curr Cardiol Rep. 2016 Aug;18(8):78. doi: 10.1007/s11886-016-0746-5. Curr Cardiol Rep. 2016. PMID: 27319008 Review.
Wearable cardioverter-defibrillators: A review of evidence and indications.Trends Cardiovasc Med. 2020 Mar 12:S1050-1738(20)30039-6. doi: 10.1016/j.tcm.2020.03.002. Online ahead of print. Trends Cardiovasc Med. 2020. PMID: 32205034 Review.